5 Churchill Livingstone is an imprint of Elsevier Elsevier Australia. ACN (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data Using evidence to guide nursing practice / editors Mary Courtney, Helen McCutcheon. 2nd ed. ISBN: (pbk.) Includes index. Bibliography. Evidence-based nursing--australia. Nursing--Decision making. McCutcheon, Helen Publisher: Luisa Cecotti Developmental Editor: Larissa Norrie Publishing Services Manager: Helena Klijn Editorial Coordinator: Lauren Allsop Edited by Alexandra Holliday Proofread by Maria McGivern Cover and internal design by Avril Makula Index by Michael Ferreira Typeset by TNQ Books & Journals Pvt Ltd Printed in Australia by Ligare

6 Contents Preface Contributors Reviewers ix xi xiii PART ONE. INTRODUCTION 1 1 Evidence-based nursing practice 3 Mary Courtney, Claire Rickard, Joy Vickerstaff and Anthea Court 1.1 Learning objectives Introduction What is evidence-based practice? What are the benefits of evidence-based practice? What are the alternatives to evidence-based practice? Why the rapid spread of evidence-based practice? Where is the evidence located? Major structures promoting evidence-based practice How can evidence be incorporated into nursing practice? What is the state of evidence? What are the challenges for nursing education and research? Discussion questions References 18 Appendix 1.1 National Institute of Clinical Studies (NICS): Resources available 21 Appendix 1.2 Joanna Briggs Institute Collaboration 23 2 Using the right type of evidence to answer clinical questions 27 Adrian Esterman, Jane Warland and Kate Deuter 2.1 Learning objectives Introduction Quantitative research designs Qualitative research designs Triangulation and mixed-method studies Hierarchies of evidence Formulating the right question Conclusion Discussion questions References 40 v

7 USING EVIDENCE TO GUIDE NURSING PRACTICE PART TWO. DEVELOPING AN EVIDENCE-BASED CULTURE 43 3 Developing a culture of inquiry to sustain evidence-based practice 45 Sonya Osborne and Glenn Gardner 3.1 Learning objectives Introduction Evidence-based practice in healthcare Culture and organisation in healthcare What is a culture of inquiry? Development towards a culture of inquiry Culture of inquiry in action Conclusion Discussion questions References 55 4 Development and use of clinical guidelines 59 Sonya Osborne and Joan Webster 4.1 Learning objectives Introduction What are clinical guidelines? What are the characteristics of effective clinical guidelines? How should clinical guidelines be used in practice? How are guidelines developed? Conclusion Discussion questions References 72 PART THREE. LOCATING THE EVIDENCE 75 5 Locating and appraising the evidence 77 David Gillham, Helen McCutcheon, Kate Deuter and Anna Holasek 5.1 Learning objectives Introduction Where should I look for evidence? Is all peer-reviewed research evidence of high quality? Examples of locating evidence Conclusion Discussion questions References 94 6 The systematic review process 97 Alan Pearson and John Field 6.1 Learning objectives Introduction The systematic review process The applicability of the evidence Software applications 105 vi

10 Preface Over the past decade, the Australian healthcare system has come under siege to improve the quality and access of patient care within a context of increasingly limited resources. Greater emphasis is being placed on the need for all health professionals to seek out evidence for best practice and apply it in their everyday work. Large gaps remain in the amount of robust evidence for much of what nurses do during the course of their daily work. Therefore, the challenge for nurses is to develop and implement well-focused evidence-based nursing interventions to improve the quality of patient care. Evidence-based practice (EBP) is fundamentally about reducing uncertainty in clinical care, in order to achieve efficient and effective service delivery. In 2005, the first edition of this book provided a guide for both experienced nurses and students of nursing on how to find, appraise and use appropriate evidence in their everyday practice. This theme continues in the second edition, with a greater emphasis on i) how to develop an EBP culture in the workplace that supports clinicians to make healthcare decisions based on finding and using the best available evidence; and ii) how to translate evidence into practice. The second edition is divided into five parts: Part one examines what EBP is. It describes the development of the EBP movement and provides an overview of why EBP has spread so rapidly over the past decade. Part one details types of evidence, describes the relationship between clinical questions and research designs to demonstrate evidence, and examines both quantitative and qualitative means of gathering evidence. Part two focuses on how to develop a workplace culture that supports EBP. It describes important features of a positive evidence-based work culture and outlines how the reader can assess their own work environment. Part two also discusses the development and use of clinical guidelines. Part three examines how to locate and appraise evidence. It also describes the process of undertaking a systematic review. Part four focuses on how to evaluate practice by undertaking a clinical audit and program evaluation. Part five examines how to translate evidence into practice, including a new case study that can be applied to this purpose. A range of discussion points and case studies are included throughout the book to assist the reader to understand the material provided in the text. If you find any errors as you read through this book, please let us know. We will acknowledge your good detective work when the book is reprinted. We will also appreciate any feedback you have that might assist in the refinement of subsequent editions of this text. Finally, many thanks to the contributing authors for providing the expertise and experience required to draw together the material for the complex issues and practices addressed in this book. Mary Courtney Helen McCutcheon ix

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12 Contributors Editors Mary Courtney, RN, BAdmin (Accounting), MHP, PhD, FRCNA, AFACHSE, Acting Executive Dean and Professor of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, Queensland Helen McCutcheon, RN, RM, BA, MPH, PhD, Professor and Head of School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia Chapter authors Kate Andre, PhD, MN, BN, FRCNA, Step 2010 Project Leader, Senior Lecturer, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia Sally Borbasi, RN, PhD, MRCNA, Professor of Nursing, School of Nursing and Midwifery, Griffith University, Brisbane, Queensland Anthea Court, MBA, Associate Director, The Joanna Briggs Institute; Field Associate, School of Population Health and Clinical Practice, University of Adelaide, Adelaide, South Australia Kate Deuter, BAppSc, Grad Cert, Research Assistant, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia Adrian Esterman, PhD, MSc, BSc (Hons), DLSHTM, Foundation Chair of Biostatistics and Professor, School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia John Field, PhD, RN, DNE, BLegSt, FCN, FRCNA, Associate Professor and Director, Research and Higher Degrees, School of Nursing and Midwifery, University of Tasmania, Tasmania Glenn Gardner, RN, BAppSc (Adv Nursg), MEdSt, PhD, FRCNA, Professor of Clinical Nursing and Director, Centre for Clinical Nursing, Queensland University of Technology and Royal Brisbane and Women s Hospital, Brisbane, Queensland David Gillham, PhD, MNSt, BN, BSc, RN, Senior Lecturer School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia Anna Holasek, BA, Dip Ed, Grad Dip Library and Information Management, User Services Librarian, The Queen Elizabeth Hospital Library, Woodville, South Australia xi

18 CHAPTER 1 Evidence-based nursing practice Mary Courtney, Claire Rickard, Joy Vickerstaff and Anthea Court 1.1 Learning objectives After reading this chapter, you should be able to: 1. understand what evidence-based practice (EBP) is 2. understand the benefits and alternatives to using EBP 3. explain what has caused the major spread of the EBP movement 4. list where evidence may be located to support best practice 5. describe two major structures promoting the utilisation of EBP in Australia the National Institute of Clinical Studies (NICS) and the Joanna Briggs Institute (JBI) 6. explain how evidence may be incorporated into nursing practice, and 7. discuss the challenges the EBP-based movement has posed for both nursing education and nursing research. 1.2 Introduction This chapter introduces the reader to the development of the evidence-based practice (EBP) movement and provides an overview of why EBP has spread so rapidly over the past 15 years. It explains how evidence may be incorporated into nursing practice and examines the challenges the EBP-based movement has posed for both nursing education and nursing research. 1.3 What is evidence-based practice? Health professionals currently advise their patients to stop smoking. Why do they give this advice? Why don t they advise them to start smoking or increase their smoking intake? The reason is that evidence is available which demonstrates: high levels of smoking are associated with increased risk of lung cancer, and stopping smoking reduces the risk of lung cancer. This is an example of evidence that can identify the cause of a disease and the effectiveness of an intervention to improve patient outcomes and decrease illness and disability. 3

19 4 USING EVIDENCE TO GUIDE NURSING PRACTICE The development of EBP can be traced back to the work of a group of researchers at McMaster University in Ontario, Canada, who set out to redefine the practice of medicine to improve the usability of information ( Lockett 1997 ). The term evidence-based practice, or EBP, has been derived from the earlier work of evidence-based medicine. Earlier years saw the development of EBP limited to the discourse of medicine ; however, more recently many other health professional groups have moved to use EBP principles in their practice for example, orthodontics ( Harrison 2000 ) and allied health therapies ( Bury & Mead 1998 ). In 1997, Sackett et al (1997 :2) published the first textbook on evidence-based medicine and defined it as: The conscientious, explicit and judicious use of current best evidence in making decisions about the healthcare of patients. In 2000, Sackett et al (2000) also included patient values as well as clinical expertise: The practice integrates clinical expertise and patient values with the best available research evidence. Critics of EBP have described it as cookbook healthcare, or the worship of science above human experience. However, these criticisms are easily defused by an understanding of the three-factor interaction that EBP promotes: the best available research evidence; clinical expertise; and patient values (see Fig 1.1 ). The Journal of the American Medical Association (JAMA) has been committed to publishing Users guides to the research literature, with an excellent series of 25 articles on the topic published from 1993 to An important resource is a compendium of these articles, with further commentary, published in book form in 2002 ( Guyatt & Rennie 2002 ). Although the guides are aimed primarily at a medical audience, they are highly appropriate for all health practitioners, including not only traditional quantitative/ epidemiological approaches but also guides to interpreting qualitative evidence for practice ( Giacomini & Cook 2000a, 2000b ). Therefore, EBP is not only applying research-based evidence to assist in making decisions about the healthcare of patients, but rather extends to identifying knowledge gaps, and finding, systematically appraising and condensing the evidence to assist clinical expertise, rather than replace it ( Elshaug et al 2009 ). Clinical expertise Patient values EBP Best available research evidence Figure 1.1 The three elements of evidence-based practice Source: Sackett et al 2000

20 1 EVIDENCE-BASED NURSING PRACTICE What are the benefits of evidence-based practice? There are benefits of EBP for patients/consumers, nurses, healthcare organisations and the community For patients/consumers To healthcare consumers, it may seem ludicrous, or even frightening, that the EBP concept is relatively new. Patients typically accept recommended care from health professionals with the unspoken assumption that the practitioner knows what works For nurses In an ideal world, nurses could keep up to date by reading all of the published literature in their relevant area. In reality, with approximately a thousand new publications each year relevant just to surgical nursing, for example, this is clearly an impossible task. EBP allows a more structured and streamlined way of keeping abreast of relevant new developments without becoming overwhelmed by information overload. EBP also allows nurses to communicate effectively with their patients and with the healthcare team about the rationales for decision making and care plans. An EBP nurse is a confident professional, feeling assured that they are providing care which is supported by facts rather than habits, and can take legal accountability for their practice For healthcare organisations A commitment to EBP philosophy allows healthcare organisations to position themselves in the market as quality institutions. An EBP-compliant institution should be less likely to attract litigation, and will be able to successfully defend the care delivered if it was in line with international best evidence at the time of care. In addition, EBP allows the scrutinising of practice for effectiveness. This process often results in practice changes that allow significant cost savings, or alternatively justify necessary additional expenditure. This is attractive to organisations frequently struggling to meet assigned budgetary limits, or lobbying government for additional funds For the community Through the utilisation of EBP, finite resources are not wasted on the delivery of ineffective interventions. Additionally, EBP limits the amount of disability and suffering throughout the community by ensuring the most current and effective care is provided. 1.5 What are the alternatives to evidence-based practice? You may be wondering how nurses made decisions about their practice before the relatively recent EBP movement, or even what the alternatives to EBP are. If we are honest, for most of our working life we function on automatic pilot ; that is, we ritualistically do things the way we have always done them, the way we were taught as a student or graduate nurse, or just in the accepted way of doing things in our current workplace. However, at times our comfort zone is challenged, and we identify a knowledge deficit when confronting an unusual or challenging problem. At times like these, practitioners may guide their practice by asking the opinion of colleagues or senior practitioners, reviewing employer policies, reading textbooks or lecture notes, leafing through nursing or other journals, and listening to speakers at professional conferences or other education forums. Can you think of some benefits and limitations to these methods of guiding practice? For example, if a decision needs to be made immediately, guidance from an experienced colleague or organisational manual provides a quick and easy reference tool. However, on the downside, even well-meaning and senior practitioners may not have

21 6 USING EVIDENCE TO GUIDE NURSING PRACTICE the latest knowledge, and policy manuals are frequently out-of-date, even if they were prepared using the best evidence at the time of policy development. 1.6 Why the rapid spread of evidence-based practice? Some of the major reasons cited by Sackett et al (1997) for the spread of the EBP movement have been the: lack of research-based information to support clinical decision making lack of research-based guidelines and protocols to use in clinical practice overwhelming volume and variability of new journal information, and inadequacy of traditional sources of information (e.g. textbooks out-of-date). However, health departments around the world are increasingly being stretched to cover ever-rising health expenditures and, with treatment and care costs increasing all the time, governments need to ensure they are using public funds for treatment and care that is effective with positive health outcomes and benefits for the public. While it may be commendable to take the view that health departments have encouraged the development of EBP because they genuinely wish for patients to receive the best available care and to have the fewest adverse events possible, unfortunately, the reality may more likely be that ineffective care and adverse events are very costly in terms of extended lengths of stay in expensive hospital beds and require additional costs such as pharmaceuticals, pathology tests and radiography. Additionally, poor patient care and mistakes also lead to threats of litigation ( Tarling & Crofts 2002 ). While EBP was initially limited to the practice of medicine it became clear that unless all the members of the health team embraced EBP it would have limited impact. 1.7 Where is the evidence located? Evidence for practice decisions is increasingly available in online format. Some resources are available free of charge, while others attract a fee for use, although staff and students of healthcare facilities and universities can usually access these through the institution at no personal cost. Many electronic resources now provide links to full-text journal articles for some records. New products are constantly being developed to allow practitioners to quickly and easily search for relevant evidence. Some of the currently well-established and recommended sources of evidence are described below CINAHL The CINAHL (Cumulative Index to Nursing and the Allied Health Literature) database covers the nursing, allied health and health sciences literature from 1982 to the present. Originally a printed index, the CINAHL database has been available as a web-based product since CINAHL includes 1.7 million records and is growing weekly. Individuals can subscribe to CINAHL for a fee; however, as most health facilities and universities are subscribers, access is available free to their staff and students. Contact your librarian to find out whether your institution has CINAHL access (see www. ebsco host.com /cinahl ) MEDLINE MEDLINE (Medical Literature Analysis and Retrieval System Online) is compiled by the US National Library of Medicine and is acknowledged as the world s most comprehensive source of bibliographic information for health. MEDLINE includes literature from the nursing, medicine and allied health disciplines, as well as the health humanities, and dentistry, veterinary, biological, physical and information science. MEDLINE has more than 17 million records dating from 1965 to the present and is

22 1 EVIDENCE-BASED NURSING PRACTICE 7 updated weekly. Subscription through various commercial platforms is available for a fee to both individuals and institutions, and is widely available for free to staff and students of subscribing health facilities and universities. MEDLINE is also available free of charge from any computer connected to the internet through a platform called PubMed (see /PubMed ) The Cochrane Library An important resource for EBP is the Cochrane Library, which is produced by the international Cochrane Collaboration. Material included has been prefiltered for quality of evidence and clinical applicability, and is updated quarterly. The Library consists of several databases. The Cochrane Database of Systematic Reviews (CDSR) was launched in 2000 and includes over 5546 full-text systematic reviews of high-quality research undertaken by Cochrane collaborators that are designed to answer specific clinical questions. The Database of Abstracts of Reviews of Effects (DARE) includes over 9025 structured abstracts of systematic reviews undertaken outside the Cochrane Collaboration. The Cochrane Central Register of Controlled Trials (CENTRAL) includes details of over 550,000 controlled trials published in journals, as well as reports from conference proceedings and other sources not currently listed in other bibliographic databases. Other materials include the Cochrane Methodology Register (CMR), the National Health Service Economic Evaluation Database (NHSEED) and the Health Technology Assessment (HTA) database. All residents of Australia can access the Cochrane Library for free online due to funding provided by the Commonwealth Government and administered by the National Institute of Clinical Studies (NICS). Follow the link to the Cochrane Library at /nics PsycINFO The PsycINFO database is the premier online collection of bibliographic references covering psychological literature from 1872 to the present, including articles from over 1300 journals. Most references include abstracts or content summaries. In addition to journal articles, many books, chapters and academic dissertations are included. PsycINFO is a fee-for-product service that is widely available at no charge to practitioners through subscribing health libraries (see /psycinfo ) Meditext Meditext was launched in 2001 and contains material from the Australasian Medical Index (AMI) compiled by the National Library of Australia. Indexed are over 150 Australian and New Zealand health journals and other materials such as conference proceedings and government reports. Many Meditext references are materials not included in MEDLINE. Some full-text documents and links to full-text articles are included. The majority of universities and health departments provide fee-free access to their staff and students. Further discussion on how to locate evidence is provided in Chapter 5, while Chapter 6 provides in-depth coverage on how to locate evidence when undertaking a systematic review The Joanna Briggs Institute The Joanna Briggs Institute (JBI) provides a database of evidence summaries (literature reviews) that review international literature on common healthcare interventions and activities. These summaries are linked to care bundles or procedures that describe and/or recommend practice. A database of systematic reviews, predominantly relevant

23 8 USING EVIDENCE TO GUIDE NURSING PRACTICE to nursing and increasingly to allied health, is also located on the JBI website. These resources are available to subscribing members of the Institute. Many Australian healthcare facilities are members of the Institute and therefore provide free access to this information for their staff. Additionally, Best Practice information sheets four-page summaries of results and recommendations for practice based on systematic reviews of research are accessible free of charge (see ) The grey literature The grey literature is a term used to refer to evidence that exists in some format but is difficult to find due to its non-inclusion in searchable bibliographic indexes such as MEDLINE, which predominantly contain references to articles in highly ranked peer-refereed journals. While some grey literature may not be contained in such journals because it is of poor quality, this is not always the case, and a thorough literature search will also make efforts to identify relevant research that may have been published only in conference proceedings, non-refereed journals, government/organisational reports, textbooks or the popular press, as well as academic theses that may not have been followed up with publication. Some efforts have been made to assist clinicians to search or access the grey literature including aspects of the Cochrane Collaboration (see Section ) and the following online instruments: the Australasian Digital Theses (ADT) Program and the Conference Papers Index The Australasian Digital Theses Program The Australasian Digital Theses (ADT) Program began in 1998 and has been open to all Australian universities since It consists of a national collaborative of digitised theses produced at Australian universities (PhD and Masters by Research theses only). The program can be accessed free of charge via any internet-connected computer (see ) The Conference Papers Index This database provides over 2.5 million citations to oral papers and poster sessions presented at major scientific conferences internationally from 1982 to the present. Major areas of subject coverage include healthcare, as well as biochemistry, chemistry, biology, biotechnology and many others. The Index is updated bimonthly and is available through subscribing health or academic institutions (see /factsheets /cpi-set-c.php ). 1.8 Major structures promoting evidence-based practice In Australia and New Zealand, the major structures promoting EBP are the National Health and Medical Research Council (NHMRC) s National Institute of Clinical Studies (NICS), the Joanna Briggs Institute (JBI), and the New Zealand Guidelines Group (NZGG) The National Institute of Clinical Studies Reliable data on the gaps between clinical evidence (what research shows that clinicians should be doing in their clinical care) and clinical practice (what is actually done) is often difficult to find. Despite this, there have been sufficient published research studies to suggest that there is a gap problem in many healthcare systems. Dutch and American studies indicate that 30 40% of patients do not receive care based on the best research evidence, and that 20 25% of the care provided is either not needed or may be potentially harmful (Grol 2001, Schuster et al 1998 ). The National Institute of Clinical Studies (NICS) is Australia s national agency for improving healthcare by helping to close the gaps between best available evidence

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